Unknown Individual – Legal Medicine, NPI 1104812619

Unknown Individual is a healthcare provider. based in Clarksville, Arkansas. specializing in Legal Medicine. They hold a License No. C4957 (AR). The NPI Number for Unknown Individual is 1104812619

Main info

Organization
Inactive
51 Years Of Experience
Accepts Medicare Assignment
Name
Unknown Individual
NPI
1104812619
Phone
(479) 754-4721
Address
23 PROFESSIONAL PARK DR
Deactivation Date
26 June 2025

Doctor Profile

Medical School Name
UNIVERSITY OF ARKANSAS COLLEGE OF MEDICINE
Secondary Phone
4797544721
Graduation Year
1975 (51 years ago)
PAC ID
4284694373
Group Practice PAC ID
8123927530
Professional Enrollment ID
I20041013000666
Data current as of
19 May 2026

Profile Insights

NPPES metrics only — not quality of care.

Methodology
Experience14
Completeness75
Years active:0State licenses:1Digital endpointsOther names

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Provider Addresses for Unknown Individual

  • 23, Professional Park Drive, Clarksville, Johnson County, Arkansas, 72830, United States

    CLARKSVILLE, AR 728304432

    Phone: (479) 754-4721

    Fax: (844) 584-4213

    Mailing address matches the actual address.

NPPES updates history

No NPPES updates recorded for this provider.

Prescription Activity

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Open Payments (CMS)

CMS reports 3 Open Payments records for all available years, with a total value of $65.

Total Amount is formed as General ($65) + Research ($0) + Ownership ($0) = $65.

Last reported payment date: 2024-11-11 • Largest payer in this snapshot: Abbott Laboratories ($37).

Total Amount

$65

General + Research + Ownership

Payments

3

Total payment records

General Amount

$65

General payments

Research Amount

$0

Research funding

Ownership Amount

$0

Ownership interests

Ownership Count

0

Ownership records

Last Payment Date

2024-11-11

Latest reported date

Top Companies

Largest payers in this snapshot

View all Open Payments →|Open Payments Risk Radar →

Medicare Enrollment & Revalidation

Source: CMS public data · Not endorsed by CMS ·

Educational use only—not medical, billing, or legal advice.

No Medicare enrollment or revalidation data available for this provider in our database.

Prepare CMS-855 application → · Look up this NPI in PECOS → · Verify on CMS PECOS

Medicare Utilization (FFS)

Source: CMS public data · Not endorsed by CMS · Beneficiary counts under 11 are suppressed in source data ·

Educational use only—not medical, billing, or legal advice.

No Medicare fee-for-service utilization data available for this provider in our database.

Insurance plans in this area (ZIP 72830)

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Provider's Procedures

Unknown Individual performs procedures in Legal Medicine. See the list of HCPCS codes below.
SpecialtyPractice State
HCPCS Code
Description
Service Count
Beneficiary Count
FAMILY MEDICINEAR83036Hemoglobin A1C level11868
FAMILY MEDICINEAR85610Blood test, clotting time8415
FAMILY MEDICINEAR94060Measurement and graphic recording of the amount and speed of breathed air, before and following medication administration1716

Group practice members

Group practice members are other physicians who share the same Group Practice PAC ID with this doctor. When doctors form a group practice and register in PECOS as a single entity, they receive a shared identification number. This table lists all providers in the same group practice.
PAC ID: 8123927530View full group profile
NameSpecialtyState
Family PracticeAR
Family PracticeAR
Family Practice, Emergency MedicineAR

Reviews

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Frequently asked questions

Does Unknown Individual share an NPI with anyone else?
NPI numbers are unique to each provider or organization — Unknown Individual uses 1104812619.
What dates should I check for Unknown Individual's activity?
We display what the registry publishes: Unknown Individual appears inactive there.
What is Unknown Individual best known for clinically?
Directory data describes Unknown Individual with Legal Medicine. Clinical services aligned with this taxonomy classification.
Where should I expect Unknown Individual on a map?
Expect Clarksville, Arkansas as a primary anchor for Unknown Individual unless the record lists multiple sites.
Why does Unknown Individual have multiple addresses?
2 practice locations appear in the available data. Multiple addresses are common for hospital privileges, telehealth, or multi-site groups.

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